Veterans and Addiction
The formal diagnosis of a substance use disorder (the current designation of either a substance abuse issue or an addiction to some substance) has been noted to have a higher probability to occur in individuals who experience some form of trauma or stress-related issue or who have some other type of mental health disorder diagnosis. Military veterans are particularly vulnerable to the development of issues regarding substance abuse. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) report the following:
- As would be expected, combat experience is associated with a significantly increased risk for the development of a trauma- or stressor-related disorder such as post-traumatic stress disorder (PTSD). In 2014, it was estimated that at least 18.5 percent of veterans returning from Afghanistan or Iraq qualified for a diagnosis of PTSD.
- Individuals with multiple deployments are even more likely to develop issues with substance abuse, including issues with binge drinking and tobacco abuse.
- Due to zero-tolerance policies, active military personnel are far less likely to use illicit drugs than civilians; however, they show increased rates of alcohol and tobacco use/abuse. This tendency to rely on alcohol and tobacco as forms of “stress release” in the military may also fuel later substance use issues in veterans.
- About half of returning military service individuals who require mental health treatment will seek treatment, but only a quarter of returning service personnel get adequate mental health treatment.
- Issues faced by military veterans in the United States include issues with past traumatic experiences, depression, suicidal thoughts, homelessness, and becoming caught up in the criminal justice system as a result of being a victim of a crime or a perpetrator.
- Despite the stereotype of US veterans having higher rates of substance use disorders than non-veterans, SAMHSA reports that about 7.5 percent of US veterans had a diagnosable substance use disorder in 2014 compared to about 8.4 percent of all Americans.
One of the Major Links between Substance Abuse and Past Military Service
Whenever the issue of substance abuse and past military service is brought up, the obvious association that also surfaces is the strong link between substance abuse and a diagnosis of PTSD. While not every veteran of military service who has a substance abuse issue suffers from PTSD, it is a relatively safe assumption to assume that the majority of individuals returning from military service who develop PTSD are at an increased risk to develop issues with substance abuse. However, numerous research studies also indicate that there are other factors associated with substance abuse in veterans.
One finding shows a significant relationship between substance abuse and depression in US military veterans. Depression is often a co-occurring issue in numerous different psychological disorders including PTSD, and it can be a standalone diagnosis itself. Research has consistently found a strong connection between substance abuse, depression, and suicidal behaviors. Research has also indicated a rising trend of depression and suicidal thoughts in active military members.
Noncombat-related stress is also a significant factor in the development of potential substance-abuse-related issues for veterans. For example, women in military service often experience significant issues with trauma and stress related to differential treatment and even harassment, which can result in the development of a formal mental health disorder, such as PTSD or depression, and increase the risk for the development of the substance abuse issue. A large number of female military veterans report issues with stress related to sexual harassment, and a surprising number of male veterans report similar issues.
Thus, while a good deal of research focuses on combat-related PTSD, it is important to note that other issues that occur in veterans, such as noncombat-related experiences and even harassment in the military, can also be contributing factors to the development of a substance use disorder in these individuals.
PTSD and Its Relation to Substance Use Disorders
PTSD is a psychological disorder that occurs in some individuals who have experienced firsthand, witnessed, or heard of someone being involved in a potentially serious, threatening event where either significant physical injury was about to occur or the individual could be potentially killed. The United States Department of Veterans Affairs has released the estimated rates of PTSD in veterans of the most recent military actions since the Vietnam War. These estimates indicate the following:
- The rates of PTSD diagnoses that occur as a result of sexual harassment or sexual abuse to military personnel are not known but are considered to be higher than the rates of PTSD that occur in individuals without a history of military service.
- Estimates regarding the rates of PTSD for returning veterans involved in the Iraqi Freedom Operation and the Enduring Freedom Operation range between 11 percent and 20 percent.
- The estimated rate of PTSD occurring in Gulf War veterans is approximately 12 percent.
- The estimated rate of PTSD occurring in Vietnam War veterans is significantly higher due to the nature of that conflict and a lack of understanding of how to recognize the disorder in individuals at that time. Those estimates run as high as 30 percent.
The formal diagnosis of PTSD requires that an individual present with a specific number of symptoms as specified by the American Psychiatric Association (APA) in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5. In general, the array of symptoms that may occur in individuals with PTSD include:
- Re-experiences of the traumatic event that can occur as very strong memories, dreams, or flashbacks (the actual experience of reliving the event again even though one is removed from it)
- Avoidance of situations, conditions, people, places, etc., that reminds one of the traumatic event
- Feelings of depression or hopelessness
- Increased hypervigilance
- Issues with suspiciousness, aggression, depressive symptoms, anxiety (including panic attacks), irritability, pessimism, and/or problems with experiencing pleasure from events that were once considered to be enjoyable or pleasurable for the person
- Marked declines in self-esteem and feelings of self-worth
- Numerous changes in thinking, such as issues with attention, issues with concentration, difficulty remembering past events or recent events, and problem-solving issues
- Issues with insomnia, decreased appetite, and/or the development of self-destructive behaviors that can include potential suicidal thoughts or even suicide attempts, marked impulsivity, and/or substance abuse
Up until recently, the symptoms of PTSD were often not recognized for a significant period of time following an individual’s combat experience. Public awareness of this potential issue and better diagnostic approaches have helped to alleviate the situation somewhat; however, it should be noted that for some individuals, significant PTSD symptoms may not occur for months and even years following their traumatic experience. Often, individuals may tolerate signs of the disorder that may not be significant enough to be considered clinically diagnosable. The longer individuals attempt to deal with these types of issues without formal intervention, the greater the chance that they may have complicated presentations of PTSD that include co-occurring conditions like depression and substance abuse.
APA reports that nearly 20 percent of veterans who have a diagnosis of PTSD also develop a substance use disorder, indicating that these individuals are at significant risk for substance abuse issues. Moreover, research has also indicated that individuals who have substance abuse issues prior to the experience of a traumatic event (e.g., combat experience) are at a greater risk to develop PTSD than individuals who do not have previous substance abuse issues. Thus, the relationship between PTSD and substance use disorders is very complicated and suggests that there is some type of a shared vulnerability between substance abuse and the development of a trauma- or stressor-related disorder.
According to APA, any substance could conceivably be abused by an individual with a diagnosis of PTSD; however, the most common are co-occurring issues with:
- Alcohol abuse
- Prescription medication abuse, particularly benzodiazepines or narcotic pain medications
- Cannabis abuse (marijuana and cannabis products)
- Illicit substances, particularly heroin and stimulants such as methamphetamine or cocaine (often abused by individuals with severe co-occurring psychological disorders, such as psychotic disorders, severe depression, or severe personality disorders)
Depression and Anxiety
According to APA, an individual diagnosed with PTSD is 80 percent more likely than an individual without a PTSD diagnosis to meet the formal diagnostic criteria for at least one other mental health disorder. These disorders include substance use disorders and issues with mood and anxiety. In addition, APA reports that nearly 50 percent of returning veterans from Afghanistan and Iraq who have a diagnosis of PTSD are also diagnosed with a mild traumatic brain injury.
Up until very recently, PTSD was actually considered to be a type of anxiety disorder (a disorder that was primarily fueled by issues with anxiety), but the DSM-5 created a new class of disorders, trauma and stress-related disorders, that includes PTSD and other related types of disorders. Veterans are particularly susceptible to issues with depression even if they do not have a formal diagnosis of PTSD and issues with anxiety.
According to Kaplan and Sadock’s Synopsis of Psychiatry, the potential to be diagnosed with a substance use disorder is significantly increased in individuals who have issues with depression, anxiety, and traumatic brain injuries. The percentage of individuals diagnosed with any one of these disorders and a co-occurring substance use disorder typically ranges from 20 percent to 40 percent, depending on the study.
Addressing Substance Abuse and Co-Occurring Issues in Veterans
Often, veterans who present for treatment with substance abuse issues have co-occurring psychological/psychiatric issues as well. It becomes extremely important for potential treatment providers to perform a full mental, physical, and social assessment of the individual to determine the entire spectrum of their issues and to develop a formal treatment plan that addresses their specific needs. The assessment should include:
- A comprehensive psychological evaluation
- A full physical evaluation
- A cognitive evaluation
- An evaluation of the individual’s social situation and support/peer group
Such an assessment is typically performed by a team of healthcare professionals, including physicians, psychiatrists, psychologists, neuropsychologists, social workers, and other healthcare workers who may be needed to investigate specific issues, such as physical or occupational therapists, speech therapists, etc. This type of approach to assessment and a later multi-team approach to treatment has been termed an integrated assessment/treatment program. The team works separately on assessing and treating specific issues and also works together according to the overall treatment plan. Team members communicate with each other regarding specific needs, progress of the individual, treatment goals, etc.
When treating a veteran with substance abuse issues who may have other co-occurring disorders, the substance use disorder treatment occurs concurrently with treatment for any co-occurring mental health conditions, such as PTSD, depression, etc. It has been well established that attempting to simply address the individual’s substance use disorder and not addressing other co-occurring issues is a strategy that will result in complete failure and a total breakdown of the individual’s substance abuse treatment program. This means that veterans with substance use disorders are often involved in very comprehensive and complicated treatment programs that address issues from numerous disciplines. Most often, these individuals will receive:
- Formal withdrawal management care (medical detox) from a psychiatrist or addiction medicine physician
- Continued medical management for any co-occurring mental health conditions and physical conditions from a psychiatrist and/or other physician
- Therapy for substance use disorders and therapy for whatever co-occurring condition may be present (e.g., PTSD, depression, an anxiety disorder, etc.)
- Support group participation for substance use disorders (e.g., 12-Step groups like Alcoholics Anonymous or other support groups) for PTSD, depression, suicidality, etc.
- Significant involvement with the individual’s family and peer group, which can occur in the form of family therapy or other types of support
- Other interventions as needed in the individual’s case (Individuals with a history of traumatic brain injury may need cognitive retraining or speech therapy; individuals who are homeless may need assistance with housing placement; some individuals may need job training or vocational rehab; other individuals may need physical therapy or occupational therapy, etc.)
The integrated treatment team will periodically meet and discuss progress toward goals, update goals, and may assign other interventions that may be needed or identify interventions that can be slowly tapered off. Often, individuals with PTSD require long-term involvement in support groups and other forms of treatment in the same way that individuals with substance use disorders often attend support groups for years after they first achieve abstinence from their substance of choice. There is a strong relationship between the length of time that individuals remain in treatment and successful outcomes, such that individuals who remain in treatment-related activities for lengthy periods of time often have the most positive and stable outcomes over the long-term. This means that individuals with substance use disorders and co-occurring disorders like PTSD are never considered fully “cured” but instead adopt the attitude that they are moving forward in the recovery process despite any success they have achieved.
Veterans who are concerned about issues with substance abuse, PTSD, or other problems can access the following resources:
- Substance Abuse and Mental Health Services Administration resources for Veterans and Military Families and SAMHSA’s Behavior Health Treatment Services Locator online or by phone at 1-800-662-HELP
- United States Department of Veterans Affairs, Treatment Programs for Substance Use Problems
- United States Department of Veterans Affairs: National Center for PTSD